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Cultural Competence Principles in
Achieving Equity in Mental Health
Care
March 21, 2015
Ranna Parekh, MD, MPH
Director, Division of Diversity and Health Equity
American Psychiatric Association
© 2015 American Psychiatric Association. All Rights Reserved.
Cultural Competence
It is the ability of mental health professionals and services to provide pa5ent-­‐centered care by taking into account the mul5ple, changing and individualized cultural iden55es of each person receiving care. © 2015 American Psychiatric Association. All Rights Reserved.
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Culture and Mental Health
•  Culture includes place of origin, race, ethnicity and others iden6fiers such as gender, age, educa6onal level, income, sexual orienta6on, religious beliefs •  Culture is dynamic and evolving •  Cultural iden6ty varies from person to person © 2015 American Psychiatric Association. All Rights Reserved.
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DSM 5 Definition of Culture
•  Values, orienta6ons, knowledge and prac6ces that individuals derive from membership in diverse social groups (ie, ethnic groups, faith communi6es, occupa6onal groups, veterans groups, etc.) •  Aspects of individual’s background, developmental experinces, current social contexts that affect his/her perspec6ve(ie, geographical origin, migra6on, language, religion, sexual orienta6on, race/ethnicity) •  The influence of family, friends and other community members (social network) on the individual’s illness experience. © 2015 American Psychiatric Association. All Rights Reserved.
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U.S. Population Changes
Majority minority by 2043
Minority births exceeded
white births as of 2011
© 2015 American Psychiatric Association. All Rights Reserved.
Population Diversity
Kentucky and US
White Black/African American Hispanic/La6no Two or more races Asian © 2015 American Psychiatric Association. All Rights Reserved.
Kentucky US 86% 8% 3% 2% 1% 63% 13% 17% 2% 5% Source: US Census 2014 6
Kentucky and US
Foreign born With disability (under age 65) Median income © 2015 American Psychiatric Association. All Rights Reserved.
Kentucky US 3% 13% 13% 8% $43,000 $53,000 Source: US Census, 2014 7
Uninsured Rates for the Nonelderly
by Race/Ethnicity, 2013
Kentucky
US
White
13%
12%
African American
11%
17%
Hispanic
N/A
26%
Other
N/A
15%%
Total
14%
15%
Sources:Kaiser Family Founda6on
© 2015 American Psychiatric Association. All Rights Reserved.
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Appalachia
•  Higher prevalence of mental health disorders in Appalachia than US (more report psychological distress and MDD) •  Higher rates of serious psychological stress and MDD in central Appalachia (vs northern and southern) •  Alcohol is predominant substance of abuse in US and Appalachia •  Methamphetamine use is rising, but rates lower in Appalachia than US Source: ARC, 2008 © 2015 American Psychiatric Association. All Rights Reserved.
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© 2015 American Psychiatric Association. All Rights Reserved.
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© 2015 American Psychiatric Association. All Rights Reserved.
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© 2015 American Psychiatric Association. All Rights Reserved.
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Reasons People Do Not Seek Help
for Mental Health Concerns
•  S6gma •  Low Perceived Need •  Cost/Insurance •  Structural Barriers •  Do Not Believe Services Would Help © 2015 American Psychiatric Association. All Rights Reserved.
•  NSHUD 2011 13
Stigma and Mental Health
The s6gma associated with mental illness prevents many individuals and families from seeking help and/or ge`ng treatment. Mental health providers need to be cognizant and sensi6ve to the shame associated with mental illness and respect individuals, families and communi6es concerns (oben related to saving face). Utmost assurance and acen6on must be paid to maintain confiden6ality. © 2015 American Psychiatric Association. All Rights Reserved.
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Access Challenges for
Underserved Populations
•  Shortage of behavioral health providers in some
areas
•  Major cutbacks in public mental health services
•  Severe lack of mental health workforce diversity
•  Transportation (physical access)
© 2015 American Psychiatric Association. All Rights Reserved.
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© 2015 American Psychiatric Association. All Rights Reserved.
Source: SAMHSA, 2013
© 2015 American Psychiatric Association. All Rights Reserved.
Source: SAMHSA, 2013
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© 2015 American Psychiatric Association. All Rights Reserved.
Source: SAMHSA, 2013
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© 2015 American Psychiatric Association. All Rights Reserved.
Source: SAMHSA, 2013
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Barriers and Mediators to Access to Equitable
Health Care for Diverse Racial and Ethnic Groups
Barriers
Personal/Family
n  Language/literacy
n  Attitudes, beliefs
n  Preferences
n  Involvement in care
n  Health behavior
n  Education/income
Structural
n  Availability
n  Appointments
n  How organized
n  Transportation
Financial
n  Insurance coverage
n  Reimbursement
levels
n  Public support
Use of Services
Visits
n  Primary care
n  Specialty
n  Emergency
Procedures
n  Preventive
n  Diagnostic
n  Therapeutic
fromPsychiatric
InstituteAssociation.
of Medicine.
AccessReserved.
to Health
© Modified
2015 American
All Rights
Mediators
Quality of providers
n  Cultural competence
n  Communication skills
n  Medical knowledge
n  Technical skills
n  Racial bias/
stereotyping
n  Appropriateness of
care
n  Efficacy
of treatment
n  Adherence to
treatment
Outcomes
Health Status
n  Mortality
n  Morbidity
n  Well-being
n  Functioning
Equity of Services
Consumer Views of
Care
n  Experiences
n  Satisfaction
n  Effective
partnership
Care in America: A Model for Monitoring Access. Washington, DC:
National Academy Press; 1993. Cooper LA, Hill MN, Powe NR. J Gen Internal Med. 2002;477-486.
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Mental Health Parity
Parity Law (Mental Health Parity and Addictions Equity
Act, 2008) mandates that employer-based health plans
must provide benefits similar to those provided for
medical/surgical conditions.
Final Rule issued in November 2013
Affordable Care Act builds on this and requires all new
plans to offer coverage for mental health and substance
use disorders at parity as a core benefit.
© 2015 American Psychiatric Association. All Rights Reserved.
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ACA and Mental Health:
Expanding Access to Treatment
Provide coverage for mental health and substance
use disorder services for all plans sold through state
exchanges
Patients can’t be denied coverage because they have
had a psychiatric illness
Eliminate the lifetime limits on services or coverages
Closing Medicare’s drug benefit “doughnut hole”
© 2015 American Psychiatric Association. All Rights Reserved.
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Health Care Reform
Contributions to Eliminating Disparities
Integrated care between primary care and mental health
•  People with severe mental illness die 25 years
sooner than those in the general population
•  70% of individuals with significant MH/SUD had at
least 1 chronic health condition, 45% have 2, and
almost 30% have 3 or more
•  Ethnically and racially diverse populations have
high rates of chronic disease and premature death
© 2015 American Psychiatric Association. All Rights Reserved.
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Health Care Reform
Contribution to Eliminating Disparities
•  Mental health parity
•  Expanding health coverage
Employer mandate, health exchanges, Medicaid expansion
•  Improving access to care
Community health centers, Indian Health Care Improvement Act, HRSA
NHSC, workforce development, behavioral health services
reimbursable in primary care
•  Culturally and linguistically appropriate information to
Medicaid and health exchange enrollees
© 2015 American Psychiatric Association. All Rights Reserved.
Kaiser Family Foundation, 2010
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Future Trends Increasing Access
• 
• 
• 
• 
• 
Peer Support Specialists Community Health Workers Promotoras Mental Health Navigators Cultural Brokers © 2015 American Psychiatric Association. All Rights Reserved.
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What is the APA Doing
to Eliminate
Mental Health Disparities
in the context of
Health Care Reform? © 2015 American Psychiatric Association. All Rights Reserved.
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APA and Diversity
Working to •  Eliminate mental health dispari6es among minority and vulnerable popula6ons •  Advance professional interests of psychiatrists from minority and underrepresented (MUR) groups •  Educate public about mental health and s6gma affec6ng assessment and 6mely treatment •  Train culturally competent psychiatrists © 2015 American Psychiatric Association. All Rights Reserved.
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APA Approach
•  Components/Governance •  Professional Educa6on/ Career Development •  Recruitment •  Public Educa6on Accomplished through •  Division of Diversity & Health Equity •  Alliance building & collabora6ons © 2015 American Psychiatric Association. All Rights Reserved.
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Career Development
Fellowships
• 
• 
• 
• 
© 2015 American Psychiatric Association. All Rights Reserved.
APA SAMHSA Minority
Diversity Leadership
Public Psychiatry
Jeanne Spurlock Congressional
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Components/
Governance Support
•  Council on Minority Mental Health and Health Dispari6es •  MUR Trustee on the Board of Trustees (began 2013) •  MUR Caucuses (7) •  Assembly Commicee of MUR Reps © 2015 American Psychiatric Association. All Rights Reserved.
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Books
© 2015 American Psychiatric Association. All Rights Reserved.
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Mental Health and Faith Community Partnership •  American Psychiatric Founda6on •  American Associa6on for People with Disabili6es/ Interfaith Disability Advocacy Coali6on •  American Psychiatric Founda6on © 2015 American Psychiatric Association. All Rights Reserved.
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Public Education
APA On Tour Community Meetings
Regional forums in areas with high propor6ons of underserved popula6ons hosted by APA’s Division of Diversity and Health Equity Discussions about mental health dispari6es and the impact on overall health, economic produc6vity and societal well-­‐being © 2015 American Psychiatric Association. All Rights Reserved.
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© 2015 American Psychiatric Association. All Rights Reserved.
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© 2015 American Psychiatric Association. All Rights Reserved.
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APA Diversity Mental Health Month
Bringing attention to
mental illness needs and
services in culturally
diverse communities
APA will celebrate in
July 2014 for the 1st time
www.psychiatry.org/diversity-­‐month © 2015 American Psychiatric Association. All Rights Reserved.
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Public Education
© 2015 American Psychiatric Association. All Rights Reserved.
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American Psychiatric Associa6on www.psychiatry.org Ranna Parekh, MD, MPH [email protected] © 2015 American Psychiatric Association. All Rights Reserved.
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